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The new DSM-5: Anxiety Disorders and Obsessive-Compulsive Disorders

C. E. Zupanick, Psy.D.

In this article, we discuss how the the former DSM-IV category of Anxiety Disorders became three separate categories in DSM-5.  These three categories are:

1. Anxiety Disorders (separation anxiety disorder, selective mutism, specific phobia, social phobia, panic disorder, agoraphobia, and generalized anxiety disorder).

2. Obsessive-Compulsive Disorders (obsessive-compulsive disorder, body dysmorphic disorder, hoarding disorder, trichotillomania, and excoriation disorder).

3. Trauma and Stressor-Related Disorders (reactive attachment disorder, disinhibited social engagement disorder, PTSD, acute stress disorder, and adjustment disorder).

Changes to Anxiety Disorders:

Aside from the removal of obsessive-compulsive disorder and PTSD into separate categories (see above), not much has changed. In keeping with the life-span, developmental approach (see newsletter #1), two disorders, which were formerly classified as childhood disorders, are now part of the anxiety disorders group. These are separation anxiety and selective mutism. Both children and adults may receive these diagnoses. Agoraphobia and Panic Disorder have been decoupled and now form two distinct disorders. Additionally, a panic attack specifier is now applicable to any diagnostic category: e.g., depressive disorder with panic attacks, PTSD with panic attacks.

A new diagnostic category: Obsessive-Compulsive and Related Disorders (OCRDs)

DSM-5 added a new category of disorders called Obsessive-Compulsive and Related Disorders (OCRDs) (also called Obsessive-Compulsive Spectrum Disorders in the research literature). The OCRDs category includes the familiar obsessive-compulsive disorder. It also includes two newly defined disorders with obsessive-compulsive features. These are hoarding disorder and excoriation (skin-picking) disorder. Also included in the new OCRD category are body dysmorphic disorder (previously classified as a Somatoform Disorder) and trichotillomania (hair-pulling, previously classified as an Impulse Control Disorder Not Elsewhere Classified).

Rationale for a separate category of disorders with obsessive-compulsive features:

Decisions about which disorders are grouped together in the DSM-5 are based on whether there is evidence of an underlying relationship between two or more disorders. This relationship may be indicated by: symptom similarity; frequency of co-occurrence (comorbidity); the onset, presentation, and progression of the disorders; genetic risk factors; environmental risk factors; neural substrates, biological markers; and treatment response. To date, the strongest evidence for an underlying relationship between the OCRDs comes from symptom similarity, as well as the high degree of co-occurrence (comorbidity) among the disorders. While anxiety remains a key feature in OCRDs, there are enough unique differences between Anxiety Disorders and OCRDs to justify a separate category.

Similarities and differences between OCRDs:

So what are the symptoms that make these disorders similar? The OCRDs are characterized by repetitive thoughts, distressing emotions, and compulsive behaviors. The specific types of thoughts, emotions, and behaviors vary according to each disorder within this group. Although there is symptom similarity and overlap, each disorder has its own unique features. These differences affect treatment decisions in several important ways: 1) the type of treatment selected; 2) the order, and pace of therapeutic interventions; and, 3) the goals and expectations of clinicians, therapy participants, and family members.

The gold standard for the obsessive-compulsive disorder remains cognitive-behavioral therapy. This generally includes exposure and response prevention. However, in order to participate in this somewhat uncomfortable therapy, sufficient motivation for treatment is necessary. This leads to an important difference between the OCRDs: insight. A person's insight into the magnitude and nature of their problems, affects their motivation for treatment. In general, persons with body dysmorphic disorder and hoarding disorder tend to have poorer insight. This limited insight requires additional therapeutic strategies to increase motivation, and to strengthen the willingness to change.

In a related manner, different OCRDs have different types of dysfunctional beliefs. Obsessive-compulsive disorder is usually characterized by irrational beliefs. For instance, it is irrational to believe you will positively get sick every time you touch a doorknob, unless you immediately wash your hands. In contrast, hoarding disorder and body dysmorphic disorders are characterized by distorted beliefs. Unlike irrational beliefs that cannot be factually supported, distorted beliefs often have a rational basis (albeit in grossly distorted form). To illustrate, let's consider body dysmorphic disorder. It is perfectly sensible and rational to believe one's personal appearance is important. However, it is a distortion of that belief if one believes their entire value and worth is determined by some small flaw or defect. Hoarding disorder provides another example of distorted beliefs. It is perfectly fine to value being thrifty and avoiding waste. However, it is a distortion of that value to believe that everything has equal value and nothing should ever be discarded.

This distinction has important treatment implications. Irrational beliefs are somewhat simpler to treat than distorted beliefs. This is because it is possible to refute (disprove) irrational beliefs. It is more difficult to challenge distorted beliefs because they represent extreme interpretations of an otherwise normal, acceptable belief, value, or practice. For instance, imagine trying to convince someone that being thrifty is harmful or wrong. It only becomes problematic when taken to the extreme. When distorted beliefs are coupled with poor insight, it is quite difficult for a person to recognize their beliefs extreme and their behavior is unhealthy. Without this recognition, motivation for treatment is poor because they see no compelling reason to change their beliefs and resulting behaviors. This is frequently a treatment obstacle that distinguishes both hoarding, and body dysmorphic disorders.

Expansion of insight specifiers and treatment implications:

Because of the important treatment implications of insight, the "with poor insight" specifier has been refined to include three degrees of insight. A person "with good or fair insight" recognizes that the house won't burn down even though they feel compelled to repeatedly check to see if the stove is turned off. A person "with poor insight" may believe the house probably will burn down without this degree of vigilance, while a person "with absent or delusional insight" remains convinced the house will certainly burn down despite all evidence to the contrary. When delusional beliefs accompanied OCD or body-focused behaviors, people were often misdiagnosed with a psychotic disorder. This led to ineffective pharmacotherapy using antipsychotic medications. SSRIs are the recommended treatment for a person with delusional beliefs associated with an OCRD, rather than antipsychotic monotherapy. The DSM-5 authors hope that the expansion and clarification of the insight specifier will facilitate more accurate diagnosis and improve treatment outcomes.

Other specified- or unspecified, obsessive-compulsive and related disorders

As with all other categories of disorders, OCRDs include an "other specified-" and "unspecified-" diagnosis. With respect to the OCRDs, the other specified obsessive-compulsive and related disorder includes presentations characterized by OCD features that cause significant distress or impairment, but which do not meet the full criteria. Some examples are body dysmorphic-like disorder with actual flaws, body-dysmorphic-like disorder without repetitive behaviors, body-focused repetitive behaviors (e.g. nail biting), and obsessional jealousy. The unspecified obsessive-compulsive and related disorder is used when the clinician chooses not to specify the reason criteria are not met, or in situations where there is insufficient information to make a more specific diagnosis.